WASHINGTON — The disastrous rollout of President Barack Obama’s signature legislation, the Affordable Care Act (ACA), has challenged the president’s famous promise: "If you like your plan, you can keep it; if you like your doctor, you can keep your doctor."

But according to Catholic and other Christian critics, Obamacare appears also to say that if a person likes his morals, he can’t keep those either.

Scott Griswold, a Catholic insurance agent in South Carolina, said health insurance has been part of his insurance business for more than two decades. But the ACA’s mandates have made him decide that his conscience won’t allow him to sell health policies in the future.

"I’m going to continue to take care of the folks I’ve sold policies to in the past, but, morally, I just can’t sell coverage for birth control, abortifacients, morning-after pills and sterilizations," he said.

New insurance plans under the ACA must include these services as an "essential health benefit," free of charge to the consumer. These services, mandated by the Department of Health and Human Services, are the core of U.S. Catholics’ legal battles with the federal government.

"I just don’t want any part of it," Griswold said.

Griswold’s dilemma is emblematic of the moral discernment that many Catholics are facing, especially those trying to buy individual health-coverage policies through state or federal health exchanges.

As people shop on the exchanges, it is an open question as to whether the policies they can apply for are going to cover abortion. People who purchase a plan covering elective abortion must also pay an abortion surcharge.

Rep. John Shimkus, R-Ill., highlighted in an Oct. 30 Capitol Hill hearing featuring HHS Secretary Kathleen Sebelius that the federal exchange does not show which plans do or do not cover abortion.

"If someone, a constituent of mine or someone in this country, has strongly held pro-life views, can you commit to us to make sure that the federal exchanges that offer that are clearly identified — so people can understand if they’re going to buy a policy that has abortion coverage or not?" Shimkus said.

"Sir, I don’t know," Sebelius admitted in reply. "I know exactly the issue you’re talking about. I will check and make sure that is clearly identifiable."

Abortion-Free Plans?

Although every state under the ACA is required to have at least one plan that does not cover abortion, that plan may not necessarily offer coverage everywhere in the state. Moreover, pointed out Susan Muskett, senior legislative counsel for the National Right to Life Committee, consumers in Rhode Island have no abortion-free options: None of the 28 plans on HealthSource RI, the state’s health exchange, exclude elected abortion. The same, Muskett said, goes for Connecticut.

"If you’re living in Connecticut or Rhode Island, you would have no choice but to purchase a plan that covers elective abortion," Muskett said. "It’s a real moral dilemma, because if you’re a low-income family on a tight budget, those federal subsidies will certainly help — but you know that if you do so, it will be covering elective abortion."

She said the federal government has until 2017 to make sure that every exchange has a multistate plan (MSP) that excludes elective abortion, but Rhode Island and Connecticut are not among the initial states with a MSP.

Catholic-run small businesses that purchase insurance for their employees through the federal and state health exchanges may also run into a similar dilemma.

"Eventually, we will probably have something on the exchange called ‘employee choice,’ where the employee will be able to choose his own plans within a certain level chosen by the employer," she said. "So if the exchange determines that they are going to utilize employee choice, then the employee could choose an abortion-covering plan, and the employer would have to pay toward that."

However, 23 out of 50 states have taken the guesswork out of abortion coverage by banning abortion as a covered benefit in health plans on the exchanges. But for persons living in the rest of the country, figuring out which plans on the exchanges do not offer abortion is a tricky matter.

Muskett said the benefit summary of a particular plan has to say whether a plan covers abortion. "But that’s the only place they have to say that," she said.

Rep. Chris Smith, R-N.J., co-chairman of the bipartisan Congressional Pro-Life Caucus, has been pushing a bill that would inform consumers up front whether the plans they are looking at cover abortion or not. The Abortion Insurance Disclosure Act would require insurance companies to disclose whether they cover abortion on advertising and marketing materials.

Cardinal Seán O’Malley of Boston, chairman of the U.S. bishops’ Committee on Pro-Life Activities, urged Congress to pass the law in a letter, pointing out that the HHS mandate creates enormous obstacles, saying that "not only may pro-life people have a very limited choice of health plans that do not violate their consciences — but the law makes it all but impossible for them to find out which plans they are."

"This should be a point of agreement between lawmakers who consider themselves both ‘pro-life’ and ‘pro-choice,’" he said. "Any claim of ‘choice’ is empty if the law conceals the facts needed to make that choice."

Limiting Access to Care?

Burke Balch, director of the Robert Powell Center for Medical Ethics at the National Right to Life Committee, said that in order to meet the law’s objectives to cut down health-care spending, most of the exchange plans have narrowed the panels of doctors and hospitals available to patients.

"Many of them are omitting major medical centers that have the availability of advanced care and cutting-edge medicine," Balch said. "What we’re already beginning to see is that people’s opportunity to get lifesaving medical treatment is being diminished."

People who have ordinary medical needs, such as breaking a leg or needing a flu shot, will continue to have their needs met.

But Balch said that the health-care law’s tradeoff — which has moral as well as monetary implications — is "that they’re limiting the ability of people to get adequate and advanced care when they are threatened with things like cancer or heart disease."

This very situation is facing Edie Littlefield Sundby, a stage-4 gallbladder cancer patient, whose existing individual policy is canceled because it does not meet the requirements of the ACA. Sundby, in an article she penned for TheWall Street Journal, shared that none of the plans offered on California’s health exchange allow her to keep her doctors: She must choose between either her primary oncologist at Stanford University, who has kept her alive, or the University of California-San Diego, which has the primary care and emergency doctors who have supported her.

"Thanks to the law, I have been forced to give up a world-class health plan. The exchange would force me to give up a world-class physician," Sundby said.

More Problems

Balch pointed out that the ACA’s mechanisms for controlling costs would put pressure on insurers participating in the exchanges to limit their expenses on medical care — or else they could lose their ability to participate in the exchange.

"The result is we are going to give insurers a very strong incentive to not even give the option of plans that cost more and are less tightly managed," he said.

The law also places a 40% excess-benefits tax on premiums starting in 2018 on employer-provided health plans that the federal government deems are "excessive." Employers sponsoring plans for their employees will have to pay a 40% tax on every dollar spent on benefits that exceed more than $10,200 for individual coverage and $27,500 for family coverage.

"The problem is that this cut-off amount, which was set in 2010 to allow most plans, is not allowed to rise with the rate of medical inflation," Balch said. "It is only allowed to rise with the rate of average inflation."

With these thresholds bound to changes in the Consumer Price Index, Balch said that more and more people will end up feeling the squeeze — and start to lose benefits as employer-sponsored plans make changes to avoid this category.

"Let’s say that medical inflation is rising like a car speeding at 60 mph, and average inflation is only speeding at 45 mph," he said. "Well, if you’re only able to go 45 mph, you’re not going to keep up with that car at 60 mph."

Balch said the eventual result will impact medical innovations. Because newer drugs are higher-priced due to the costs of research and development, companies will have a harder time finding markets that will pay for the drugs and may choose not to cover them at all.

"It will eventually start cutting into the treatments that we have on the high-cost end."

Christian Alternatives

The moral challenges of abortion coverage, birth-control mandates and medical rationing posed by the ACA have prompted many to look at alternatives to the insurance system. The ACA carved out an exception that allowed medical cost-sharing cooperatives to fulfill the law’s insurance requirements.

Three major Christian medical-sharing ministries are Samaritan Ministries, Christian Medi-Share and Christian Healthcare Ministries, and each has its own way of helping families meet their health-care needs, sharing in their burdens and praying for one another.

At Samaritan Ministries, the largest Christian health-care sharing ministry, members share the burden of costs for needs over $300. Each member commits to sending a set "share" amount each month based on household size. These "share" amounts are matched through Samaritan’s database to a household in need and then are sent directly to that household to pay medical bills.

Christian Medi-Share has a variety of sharing options with monthly fees that vary based on what it calls the Annual Household Portion (AHP), the dollar amount that a family will be responsible for before it can publish its medical bills for sharing. So a household with an AHP level of $1,250 would pay its annual medical bills up to $1,250. After that, all other household medical bills up to $1 million for the entire year are then shared among its membership.

Christian Healthcare Ministries has three sharing plans: gold, silver and bronze. The gold plan has a higher monthly participation fee, but the amount of personal responsibility for bills is lower, and the number of eligible bills for sharing (including maternity) is greater. Bronze has the lowest monthly cost, but a person in that plan only submits bills for inpatient and outpatient hospital treatments and surgery.

James Lansberry, executive director of Samaritan Ministries, said the ACA has made sharing ministries like Samaritan more widely known, and the company has seen a lot of growth from people looking for an alternative to health insurance that fits their practice of faith.

"We do not share in abortion; we do not share in other things we find morally objectionable," said Lansberry. "We’re trying to balance two things: one, that each member should bear his own load — and that we should also bear one another’s burdens, and so follow Christ."

Lansberry said Samaritan’s members make their own decisions with their chosen medical professionals in how they treat all sorts of medical conditions, including life-threatening conditions like cancer. The inspiration for these health-care sharing ministries comes from the example of the early Christians.

"Our job as Christians is to bear one another’s burdens. It’s not to make your health-care decisions for you or predict what will happen," he said. "It is just: Here are the burdens that have come up in the last 60 days, and here is what we are going to share in these burdens; and we will take care of it as a big family."